For questions please call 916-558-5898 or email ccir@dor.ca.gov

* 1. Employer Name

* 2. Street address of location where you would like to receive DOR CC&IR Services

* 3. City

* 4. Zip Code

* 5. County

* 6. Name of Employer Contact Person

* 7. Phone number of Employer Contact Person

* 8. Email of Employer Contact Person

* 9. Number of employees employed prior to July 22, 2016 earning subminimum wage that you are requesting CC&IR services for at this time

* 10. Number of employees hired on or after July 22, 2016 earning subminimum wage that you are requesting CC&IR services for at this time

* 11. Is this request a "make-up" session for subminimum wage employees who missed a previously scheduled CC&IR meeting?

* 12. Does your agency have 15 or fewer total employees?

* 13. Please indicate accommodations needed

* 14. Comments

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